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Student Request forMPH Field Practice

MPH students should complete this form at least 3 months prior to the desired semester start date. Review the Field Practice (FP) eligibility, guidelines, and suggested resume format at not make contact with any potential field organization until you receive specific clearance from field practice coordinator or academic advisor.Email completed request form plus resumeto Julie Grubaugh, MPH field practice coordinator, . VPH students send to VPH academic advisor.
Student Name / Address / Phone / Email / Concentration / Advisor

PH-11a

Revised: 7/20/2016

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What semester and year do you expect to graduate? ______

Are you pursuing a health policy certificate? ______

Are you pursing an Epi minor? ______

What semester and year are you requesting to complete field practice? ______

Are you seeking aStandard or Extended placement?______

  • Standard 360 field hours: PUBH 587 (3 credits) and PUBH 588 (3 credits) = 6 credit hours
  • Extended480 field hours or 360 field hours if located outside driving distance of Knoxville: PUBH 587, 588, and 589 (total 9 credit hours). PUBH 589 may replace one of the two required electives.

If Extended (check one): _____360 hours (must be out of driving distance of Knoxville) or _____480 hours

I have reviewed the following (which are located on the FP webpage / Yes / No
Eligibility for Field Practice
Field Practice Guidelines
I have a 3.0 GPA or higher.
I will have completed all coursework prior to Field Practice / *

*Most (or all) MPH courses should be completed before field practice. Exceptions may be approved on a case by case basis (requires signatures below).

  • What MPH course(s) would you like to take during FP?
  • What MPH course(s) will you need to take after FP? (please include rationale and semester planned)

Eligibility approved by Academic Advisor: ______

Eligibility approved byFP Coordinator: ______

  1. Internship hours may be completed on a full-time(40 hours per week for 9 weeks) or part-time basis (24 hours per week for 15 weeks),if mutually agreeable to the intern and field preceptor.
  2. Do you prefer a full-time or part-time internship? ______
  3. List your GRA hours and assigned faculty (if applicable)______
  4. work hours you will have that semester. ______
  5. Other comments about your schedule:______

Note: In general, students do not pursue FP at their current worksite. Exceptions require approval and must be arranged in a different area of the worksite, with a different supervisor, and different roles / responsibilities.

  1. Capability to relocate for field practice (check all that apply):

______No, must remain in Knoxville area

______Yes, only within 50 mile radius (driving range) of Knoxville

______Yes, inside the state of Tennessee

______Yes, outside the state of Tennessee

  1. If outside of Tennessee, what is your preferred location?
  2. Is funding essential? ____Yes ____No
  3. Availability of transportation? ____Yes ____No
  4. What are your career goals immediately following graduation? In 5 years? In 10 years?
  1. Where do you want to live after graduation?
  1. Your field practice should (ideally) be in the city you wish to live and should (absolutely) advance your career goals. With that in mind, what is thespecific agency or type of agency(i.e.-local, state, or federal govt; non-profit, for-profit, hospital, school, etc.) with which you would like to complete field practice?
  1. Why are you interested in this agency or type of agency?
  1. What public health competencies do you want todevelop during your field practice? These are the skills that will help the preceptor identify appropriate project(s) for you. Select at least one core and two concentration competencies, located here
  1. List potential preceptor(s) or specific organization(s) and contact information.
  1. List any professional degrees or licenses that you hold.
  1. List major work experiences which may be relevant to field practice.
  1. Other comments:

PH-11a

Revised: 7/20/2016